Free Washington Claims Forms

67 Forms found in Washington — Claims — Workers Comp — Page 1 of 2
Title Last Updated
Occupational Disease Work History (Spanish) July 18, 2019
Statement For Pharmacy Services July 11, 2019
Occupational Disease Work History July 11, 2019
Transfer Of Care Card June 14, 2018
Statement For Retraining And Job Modification Services June 14, 2018
Providers Request For Adjustment June 14, 2018
Employment History Hearing Loss (Continuation) June 14, 2018
Occupational Hearing Loss Questionnaire May 2, 2017
Employment History Hearing Loss May 2, 2017
Employers Job Description May 2, 2017
Travel Reimbursement Request May 2, 2017
Interpretive Services Appointment Record May 2, 2017
Hearing Services Worker Information May 2, 2017
Application To Reopen Claim Due To Worsening Of Condition May 2, 2017
Authorization To Release Claim Information May 2, 2017
Pre Job Accommodation Assistance Application May 2, 2017
Statement For Home Nursing Services September 5, 2014
Provider Account Application September 5, 2014
Resource Utilization Group (Rug) Residential Care Services For Injured Workers December 10, 2012
Resource Utilization Group (Rug) Residential Care Services For Injured Workers December 10, 2012
Provider Credentialing Change Form December 10, 2012
Provider Credentialing Change Form December 10, 2012
Physical Therapy Treatment Authorization Fax Request December 10, 2012
Consultation Or Referral December 10, 2012
Provider Accounts Change Form November 17, 2011
Homeowners Manufactured Mobile Home Variance Request November 17, 2011
Request For Manuals From Claims Training October 27, 2011
Address Change Request For Pensioners October 27, 2011
Opioid Progress Report Supplement Chronic Noncancer Pain October 21, 2011
Authorization For Deposit Of Payment October 21, 2011
Job Modification Assistance Application November 8, 2010
Hearing Impairment Calculation Worksheet August 3, 2009
Case Transfer Card September 18, 2008
Medical Forms Request April 8, 2008
Doctors Estimate Of Physical Capacities April 8, 2008
Claim For Pension By Spouse Or Children April 8, 2008
Claim For Pension By Dependents April 7, 2008
Resource Utilization Group (Rug) Residential Care Services For Injured Workers March 13, 2008
Second 52 Week Period Board And Room Cost Encumbrance March 13, 2008
Second 52 Week Period Return To Work Plan Time Encumbrance March 13, 2008
Second 52 Week Period Transportation Cost Encumbrance March 13, 2008
First 52 Week Period Training Plan Cost Encumbrance March 13, 2008
Second 52 Week Period Training Plan Cost Encumbrance March 13, 2008
First 52 Week Period Return To Work Plan Time Encumbrance March 13, 2008
First 52 Week Period Board And Room Cost Encumbrance March 13, 2008
Declaration Of Entitlement For Widow Or Widower Benefits March 10, 2008
First 52 Week Period Transportation Cost Encumbrance March 10, 2008
Declaration Of Entitlement For Totally Disabled Worker Benefits March 10, 2008
Declaration Of Entitlement For Guardian Benefits March 10, 2008
Declaration Of Entitlement For Dependent Of Deceased Worker Benefits March 10, 2008